Assessment of knowledge, attitude, and practice regarding the disposal of expired and unused medications among the Lebanese population

Background Medication waste is a public health problem affecting developed and developing countries. In Lebanon, a developing country in the Middle East, efforts are being deployed in hospitals but not in the community. Objective This study aimed to validate a questionnaire to explore the knowledge, attitude, and practice (KAP) towards the disposal of unused and expired medicines among the Lebanese population and then identify the factors associated with these variables comparatively between the general population and healthcare professionals. Methods A cross-sectional study was conducted among the general Lebanese population in May–June 2022 using a standardized questionnaire. The validity and reliability of the KAP scales were assessed, then a thorough statistical analysis was done to explore the factors associated with these scales. Results The KAP scales generated by this study were valid and reliable. Using these scales, 24.5%, 22.6%, and 21% of participants demonstrated proper knowledge, attitude, and practice, respectively. Higher knowledge scores were significantly associated with female gender (Beta = 0.97), a high monthly income (Beta = 1.68), a secondary (Beta = 6.11) or university (Beta = 6.80) education level, and postgraduate education (Beta = 7.13). However, older age (Beta = − 0.06) and a low monthly income (Beta = − 3.06) were significantly associated with lower knowledge scores. A higher knowledge score (Beta = 0.06) was significantly associated with a more positive attitude regarding unused or expired medication disposal. Being a healthcare professional (Beta = 0.72) was significantly associated with a higher practice score, while being a female (Beta = − 0.32) and living in a rural area (Beta = − 0.37) were significantly associated with lower practice scores. Conclusion This study validated KAP scales regarding medication waste in Lebanon and showed low KAP scores in the majority of respondents. Factors associated with higher KAP scores in various aspects of medication disposal, including gender, age, education level, and profession (healthcare professionals), suggest the need to consider those when implementing targeted corrective measures. Although further studies are required to confirm our findings, this study could be the ground for a medication waste management national strategy in Lebanon. Supplementary Information The online version contains supplementary material available at 10.1186/s40545-022-00506-z.


Background
Medications are effective and safe if stored under the appropriate conditions mentioned on the label and used before the expiry date is reached [1]. Manufacturers and some health organizations advise disposing of medications by their expiry date [2], as expired medications may decompose and become ineffective or even dangerous. Further, their rational use is being highlighted, given their growing consumption worldwide. In many instances, prescribed medications remain unused because of treatment changes, side effects, patient health improvements, or other factors [3]. According to the World Health Organization, a large amount of medicine is inappropriately prescribed or sold, resulting in tons of solid waste of expired and unused medications and a medication disposal burden [3].
Inappropriate disposal of medications endangers human health and ecosystems [4]. Some people keep unwanted, unused, or expired medications in their homes indefinitely, while others dispose of them in general municipal waste bins or sinks, or flush them down the toilet [4]. Consequently, trace amounts of pharmaceuticals and their metabolites have been identified in some drinking water supplies, exposing humans to the accumulation of these traces through contaminated drinking water [5]. Waterways have also been found to contain antibiotics, antidepressants, and hormone replacement therapy [6]. Inappropriate medication disposal also leads to the potential risk of medication abuse related to narcotic pain relievers and sleep aids and could contribute to antimicrobial resistance [4]. Children and pets could also be at an increased risk of accidental poisoning due to the ease of access to unused, inappropriately discarded, or insecurely left-at-home medications [7].
Several studies have revealed a lack of proper disposal of unused or expired medications, particularly in developing countries. For example, a study in India showed that only 39% of the studied sample were aware of appropriate disposal methods for expired medications [8]. Similarly, the majority of study participants in Turkey disposed of pharmaceutical waste against national and international policies [9]. The situation is almost the same in Kuwait, where 76.5% of the surveyed population threw unwanted drugs in the garbage, and 11.2% flushed them down the drain [10]. A Saudi Arabian study found that 48.1% of participants discarded expired medications in household garbage [11]. In 2022, only 6.5% of Saudis had proper knowledge of expired medication disposal [12]. Other studies from around the world, including developed countries with guidelines and regulations, have revealed that disposal via the solid waste garbage stream, sink, and toilet is common practice [13][14][15][16][17][18][19][20][21][22]. In Lebanon, a study among residents in the administrative area of the capital city, Beirut, showed that 78.3% of respondents disposed of unwanted solid-form medications in garbage, 6% flushed them down the toilet or sink, 8.5% gave them to dispensaries or people in need, and 3.6% returned them to the pharmacy. The percentages were similar for liquid medications [23]. This improper disposal of expired medications has detrimental effects on the environment, especially with the increased hoarding in the era of COVID-19 [24]. Furthermore, many countries lack regulations and programs for the appropriate management of medication waste [25].
Besides their harmful effects on ecosystems and health, medication waste products also have unfavorable economic consequences, straining healthcare systems globally. In 2012, medication waste and suboptimal use of medicines accounted for around £300 million and more than $418 billion in England and the United States (US), respectively [26]. A study from 2003 found that families in Saudi Arabia and other Gulf countries spent a total of around $150 million on unused medicines [27].
Based on the above, waste prevention strategies are warranted at all levels (prescriber, dispenser, and patient) to reduce the economic and environmental burdens of medication waste [27] and align with the United Nations' Sustainable Development Goals [28], mainly good health and well-being (SDG3), clean water and sanitation (SDG6), sustainable cities and communities (SDG11), and life on land (SDG15), and the International Pharmaceutical Federation's Development Goals [29], including patient safety (DG19) and sustainability in pharmacy (DG21). Patients are encouraged to make savvy purchases, buying instead of hoarding the medicines they need, and pharmacists can play an essential role in reducing their stock, educating patients about waste, and dispensing medications judiciously [7,27]. Safer disposal methods should also be adopted, similar to those in developed countries.
In the US, the Food and Drug Administration (FDA) issued guidelines to consumers on where and how to dispose of unused medicines, stating that the best way to dispose of unused or expired medications is to place In contrast, non-flush list medications should be mixed with an unappealing substance such as dirt, cat litter, or used coffee grounds, placed in a sealed plastic bag, then thrown in the trash [22]. In Dubai, the Ministry of Health and Prevention launched an e-service to dispose of unused or expired drugs in 2020 [30]. In Lebanon, some efforts are being made in this regard, but the system is still not functioning adequately. The Ministry of Public Health (MOPH) has issued several decrees in the past years to regulate healthcare waste generated by hospitals, not those produced by the general population, following various laws and international conventions [31]. In community pharmacies, suppliers either return money or replace near-expiry goods with newer ones six to twelve months before they expire (it is of note that due to the current socioeconomic and sanitary crises, this procedure is not functioning correctly, and pharmacists are not able to return any expired medications to suppliers). At any point beyond this moment, pharmacies are no longer liable for the consequences of improperly discarding medicines or how this might affect the environment; expired drugs fall then into the hands of the Lebanese Pharmaceutical Importers and Wholesalers Association (LPIA), which bears the responsibility for destroying medications in local incinerators when available or exporting them to be destroyed abroad [32].
In light of this context, with the increasing consumption of medicinal products, the inappropriate disposal of unused and expired medications could cause environmental harm and public health problems. Exploring the current knowledge, attitude, and practices towards medication disposal of the general population provides insight into this matter and helps minimize medication waste, implement efficacious measures and proper disposal guidelines, and improve public awareness [33]. Since the only previous Lebanese study [23] targeted a sample from the administrative region of Beirut only and did not use validated tools to assess the disposal of pharmaceuticals in Lebanese households, it was deemed necessary to explore the knowledge, attitude, and practices (KAP) of the general population and healthcare professionals regarding the various aspects of medication disposal to help develop new strategies to improve the use and disposal of medications. Moreover, since KAP aspects would be better assessed using a valid and reliable instrument, such an instrument would also allow the determination of the facilitators and barriers to proper practice [34]. Therefore, this study aimed to validate a questionnaire to explore KAP towards the disposal of unused and expired medicines among the Lebanese population and then identify the factors associated with these variables comparatively between the general population and healthcare professionals.

Study design
An observational cross-sectional study was conducted in May-June 2022 among 415 Lebanese adults (including non-healthcare and healthcare professionals). Participants were recruited from all Lebanese districts using a snowball sampling technique and received no incentive for their participation, which was voluntary.

Sample size
In the absence of similar studies in Lebanon, the Epi-Info 7 software was used to calculate a minimum sample of 384 participants, assuming that the percentage of participants who can be considered knowledgeable about medication disposal is 50%, with an acceptable margin of error of 5%. Accordingly, the survey portal was closed when the number of responses exceeded the minimum required.

Data collection
An online questionnaire in Arabic and English (Additional file 1) was created on Google Forms (https:// forms. gle/ bQNTG RfeFW LgUL8 b6). The link to the questionnaire was shared via WhatsApp and other social media platforms. Participants were also encouraged to disseminate the survey to others using the snowball technique, thus reaching people from all Lebanese districts.
The study scope and purpose were explained at the beginning of the questionnaire. Participants were informed that their participation in the study was voluntary, and they were assured that their responses would remain anonymous and confidential. The Institutional Review Board at Beirut Arab University approved the study.

Data collection tool
The 40-item questionnaire included two main sections: sociodemographics and knowledge, attitudes, and practices related to the disposal of unused and expired medications. Age, gender, marital status, level of education, region, career, household income, household crowding, and the presence of a healthcare professional in the family were all covered in the sociodemographic part.
Questions related to waste KAP were retrieved from several articles and modified to fit the purpose of the study after a thorough review of the literature [8, 9, [35][36][37][38]. The questions were reviewed by ten of the authors of the manuscript for content validity: these authors are mid-career/senior pharmacists and members of the Order of Pharmacists of Lebanon Scientific Committee-Environment and Public Health Subcommittee. Several rounds of discussion using the Delphi method were conducted to reach the consensus on 31 questions. After identification of the problem area of research and defining the objectives of the questionnaire, the panel members searched the literature for previously published tools and potential items to be added to the questionnaire [8,9,[35][36][37][38]. Tools and items were sorted and pooled in a list of items, and circulated for controlled feedback among the panel members. Items with less than 90% consensus were discussed to be kept, modified or removed from the final list. Afterward, the KAP scale was further assessed for construct validity and reliability (see the Statistical analysis section). Sixteen questions explored participants' knowledge of expired and unused medications, medication waste, domestic use, and risk of harmful effects), while 7 questions queried their attitude (mainly their opinion on how to solve the medication waste issue) and 8 questions investigated their practices related to the disposal of expired and unused medications. The total scores were calculated by summing up all the correct/positive answers to the knowledge, attitude, and practice questions.

Statistical analysis
Data were analyzed on SPSS software version 25. A descriptive analysis was performed using absolute frequencies and percentages for categorical variables and means and standard deviations (SD) for quantitative measures.
Construct validity of the knowledge, attitude, and practice scales was assessed using principal component analysis (PCA). The Kaiser-Meyer-Olkin (KMO) and Bartlett's test of sphericity were calculated to ensure the model's adequacy. Factors with Eigenvalues > 1 were retained, and the scree plot method was used to determine the number of components to extract [39]. Moreover, the internal consistency of the studied scales was assessed using Cronbach's alpha: internal consistency values of α ≥ 0.7 and ≥ 0.8 were considered acceptable and excellent, respectively [40]. These variables were deemed normally distributed, as verified by the visual inspection of the histogram, while the skewness and kurtosis were below |1.96|. When applicable, the normality of the scales used was verified by the normality line of the regression plot and the scatter plot of the residuals. Also, KAP scores were dichotomized into good and inappropriate with a cut-off point of 75%, where good KAP was reflected by a score of 75% and above and inappropriate KAP by a percentage strictly below 75%.
In the bivariate analysis, the independent-sample t-test was used to compare the means of the KAP scales between two groups, whereas the ANOVA test was used to compare three or more means. The Pearson correlation test was used to correlate continuous variables. A p-value less than 0.05 was considered significant.
After that, three linear regressions using the Enter method were performed, taking the KAP scales as the dependent variables. In the first linear regression, the knowledge scale was taken as the dependent variable and sociodemographic characteristics as the independent variables. In the second linear regression, the attitude scale was taken as the dependent variable, and knowledge and sociodemographic characteristics as the independent variables. In the third linear regression, the practice scale was selected as the dependent variable, and knowledge, attitude scales, and sociodemographic characteristics as the independent variables. Variables that showed a p-value < 0.2 in the bivariate analysis were included in the multivariable models to decrease potential confounders.

Description of sociodemographic characteristics
The sociodemographic and other characteristics are displayed in Table 1. The mean age of the participants was 24.30 ± 9.20 years, and the mean household crowding index was 1.23 ± 0.79. Most participants were females (64.18%), single (80.1%), unemployed (66.9%), nonhealthcare professionals (69.4%), had a university education level (77.4%), a low to no monthly income (60.4%), and lived in an urban city (75.0%), notably Beirut and Mount Lebanon (73.1%). Table 2 describes the source of information of participants about medication disposal. More than half of the participants (56.9%) agreed that they ask the pharmacist about the storing instructions when buying new medications, and 52.8% reported getting their information about the proper disposal of expired medicines from personal readings. Only 28.3% declared never having received any information on how to dispose of unused or unwanted medications, and 44.8% admitted that they had never heard of medication waste.

Factor analysis of the KAP about medication waste scales
The knowledge scale items produced four factors with an eigenvalue over 1 accounting for a variance of 56.11% (Bartlett sphericity test p < 0.001; KMO = 0.823; Cronbach's alpha = 0.784). Regarding the attitude, three factors were yielded with a total variance of 63.18% (Bartlett test of sphericity p < 0.001; KMO = 0.690; Cronbach's alpha = 0.598). The practice scale produced two factors accounting for a variance of 40.01% (Bartlett test of sphericity p < 0.001; KMO = 0.675; Cronbach's alpha = 0.545) ( Table 3).
The majority of the participants considered expired and damaged medications medication waste (85% and 87.2%, respectively), but not leftover medications (71.6%). When questioned about medication disposal, most participants did not know about the appropriate way to dispose of it (garbage bin at home, flushing down the toilet), nor about the medication take-back system, although more than half of them (52.6%) agreed or strongly agreed that these programs should be mandatory. Also, 57.3% of participants agreed/ strongly agreed that there is a lack of information regarding the safe disposal of unused/expired medications and considered that they should ask a healthcare professional about how to handle this situation. Nevertheless, they were not sure whether these professionals could provide proper advice and information (32.8% neutral). The majority were aware that improper disposal presents a potential risk at home and could affect the environment and children's health (Table 4).
Most participants agreed on the need for a program to collect unused medicines from home (590; 80.3%). Several options have been suggested to reduce medication waste, including proper advice to consumers (91.3%), dispensing medication only as required (87.3%), rational prescribing (83.3%), and donating non-expired medications to those in need (79.5%) ( Table 5).
When asked about their practice, most participants reported they do not read any instructions related to medication disposal (41.1%), and they keep non-expired unused medications at home until expiration (60.3%). The most common way of disposing of expired medication was by throwing it in household garbage (70.9%); it is usually discarded as it is (64.4%) ( Table 6).

Bivariate analysis
Bivariate analyses showed that higher knowledge scores were significantly associated with the female gender, having a university education level, and having a high monthly income compared to other groups. Also, being a physician or a nurse was significantly associated with lower knowledge scores.
A higher attitude score (r = 0.295, p < 0.001) was significantly associated with higher knowledge; however, older age (r = − 0.085, p = 0.021) was related to a lower knowledge score (Table 7). Considering the attitude scale as the dependent variable showed that higher attitude scores were associated with being a female vs. male, being married vs. single, being employed vs. unemployed, having a university education level, and having a high monthly income vs. other groups. Also, older age (r = 0.076, p = 0.039) and higher knowledge (r = 0.295, p < 0.001) and practice (r = 0.179, p < 0.001) scores were significantly associated with higher attitude scores (Table 7).
Taking the practice scale as the dependent variable in the bivariate analyses showed that living in an urban vs. rural area and having a high monthly income, being a healthcare professional, or having a healthcare professional in the family were significantly associated with a higher practice score. Also, a higher attitude score (r = 0.179, p < 0.001) was significantly associated with a higher practice score (Table 7).

Multivariable analysis
A first linear regression taking the knowledge scale as the dependent variable showed that the female gender (Beta = 0.97), high monthly income (Beta = 1.68), a secondary (Beta = 6.11) or university (Beta = 6.80) education level, and postgraduate education (Beta = 7.13) were significantly associated with a higher knowledge score. However, older age (Beta = − 0.06) and a low monthly income (Beta = -3.06) were significantly associated with lower knowledge scores (Table 8, model 1).
A second linear regression taking the attitude scale as the dependent variable showed that the female gender (Beta = 0.36) and a higher knowledge score (Beta = 0.06) were significantly associated with a more positive attitude regarding the disposal of unused or expired medications (Table 8, model 2).
A third linear regression taking the practice scale as the dependent variable showed that being a healthcare professional (Beta = 0.72) was significantly associated with a higher practice score. However, being a female (Beta = − 0.32) and living in a rural area (Beta = − 0.37) were significantly associated with lower practice scores (Table 8, model 3).
When considering the different categories of healthcare professionals or having a healthcare professional in the family, none of the categories were associated with the total practice score (p > 0.05 for all) (Additional file 2).

Discussion
This study first aimed to validate a questionnaire assessing KAP toward unused or expired medications. To the best of our knowledge, it is the first to perform such a validation in Lebanon. Other studies have developed and validated questionnaires related to KAP regarding unused medications at home (QUM-Qatar [33] or ReDiUM in Malaysia [36]). In our study, using the Promax rotation, the PCA showed good internal consistency (IC) for the knowledge scale (Cronbach's alpha of 0.784), similar to what was reported in the Malaysian study (overall Cronbach's alpha value was 0.727) [36]. However, the IC values for the attitude and practice scores were lower than those reported in the Qatari study [33] (0.598 and 0.545 versus 0.82 and 0.84, respectively), suggesting the need to improve the current questionnaire for a better assessment of appropriate disposal measures in future studies.  Our study also assessed correlates of the KAP scales, which would allow for implementing targeted interventions at the national level. Our results highlighted poor knowledge of the general population of medication disposal (only 24.5% had good knowledge according to our score calculations). Most participants admitted having a lack of adequate information and clear instructions regarding the best disposal method, similar to previous findings in several other countries, such as Saudi Arabia, New Zealand, Bangladesh, Malta, and Ireland [12,22,41].
However, a higher perceived knowledge score was noted in participants with intermediate and higher education levels (secondary, university, or postgraduate versus illiterate) and higher incomes, as published elsewhere [42]. A possible explanation could be that people with higher levels of education and more stable financial conditions tend to seek information more intuitively than others and have a better grasp of their surroundings. Conversely, similar to other researchers' results, less educated participants are more likely to experience difficulties seeking new information and might not be aware of the consequences of improperly disposing of medicines [43].
Knowledge and attitudes were significantly associated with gender, with females scoring significantly higher on both. Results related to attitude are consistent with previous findings from Saudi Arabia, showing that females were significantly more willing to use medication collection facilities than males and considered having more individual responsibility for appropriate medication disposal [41,44].
As for practice, the most common method used for expired medication disposal was household garbage, in line with the results of a 10-year literature review (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015), including Kuwait, Qatar, Saudi Arabia, the United Kingdom, and India, among others [45]. Furthermore, our study revealed that most participants did not read any instructions related to medication disposal, and they kept non-expired unused medications at home until their expiration. This finding is particularly alarming in a country such as Lebanon, where most medications, including some antibiotics, can be accessed without a prescription, mainly in lower socioeconomic communities [46]. Also, both the current steep economic crisis that resulted in the local currency devaluation and the COVID-19 pandemic compelled people to hoard medications at home, thus anticipating the lifting of subsidies on some pharmaceuticals by the central bank [47,48]. One could expect that a substantial amount of these medications might not be used and would therefore end up being thrown in the garbage. This harmful practice should be controlled, and the relevant authorities are urged to promote other disposal methods, such as medication take-back sites, where consumers can drop off expired or unwanted medications.
Interestingly, participants believed they should ask healthcare professionals about the proper disposal  methods, but were skeptical about their ability to provide adequate information. Nevertheless, multivariable analyses have shown that all healthcare professionals, including pharmacists, physicians, dentists, and nurses, had significantly higher practice scores than non-healthcare professionals. This result is not surprising since healthcare workers are the key personnel responsible for medication and medical waste management [49].

Implications for practice
Taken together, our results emphasize the need for a national waste management strategy that defines the roles of healthcare professionals, governmental and non-governmental organizations, and the pharmaceutical industry. Educational campaigns offered by different parties, including media, schools, pharmacists, and other healthcare professionals, can raise awareness about the environmental problems stemming from pharmaceutical residues and the proper measures and disposal standards to reduce medication waste. [12,49,50]

Limitations and strengths
Our study has some limitations. Its cross-sectional design does not allow for causal inference. Although the sample size was sufficient for statistical analyses to be carried out, the results could have been more representative with a larger sample. Another limitation was that participants were recruited using an online questionnaire; most of them were young, lived in urban areas, had a high level of education, and had good computer literacy. Hence, our findings might not be generalizable to the entire population [45]. Furthermore, some participants may not have admitted to inappropriate medication disposal to please researchers, leading to social desirability bias or even recall bias. Nevertheless, this bias was minimized by assuring the participants of the study anonymity and the importance of their frankness. Despite all these limitations, our study is still among the very few in the region to have validated a KAP questionnaire about the disposal of unused or expired medications for construct validity and reliability.

Conclusion
This study revealed relatively low levels of knowledge, attitude, and practice related to medication disposal in Lebanon. Participants admitted having a lack of information and agreed on the need for specific programs for medication waste management. Several factors were shown to be associated with higher KAP scores in various aspects of medication disposal, including gender, age, education level, and profession (healthcare professionals), suggesting the need to consider those when implementing targeted corrective measures. This study could be the ground for a medication waste management national strategy in Lebanon. From a research perspective, it showed the need to develop a more comprehensive questionnaire to have better insight into KAP regarding the disposal of unused and expired medication among the general population and to expand it at a later stage to evaluate biomedical waste management among healthcare professionals.